Medicare’s Therapy Cap Exceptions Process Extended for 2013

Medicare’s Therapy Cap Exceptions Process Extended for 2013

Through passing the American Taxpayer Relief Act of 2012 (ATRA), Congress yet again avoided cuts to the Medicare physician fee schedule and extended the therapy caps extension process through December 31, 2013.

This extension, section 603 of ATRA, means that Medicare beneficiaries who are receiving medically necessary physical therapy, occupational therapy, and/or speech language pathology services and reach the 2013 threshold amount of $1,900 may continue to receive their Medicare-covered therapy services. As long as the therapy provided is reasonable and medically necessary, requires the specialized skills of medical professional, can be justified by supporting documentation in the beneficiary’s medical record, and their provider submits a “KX modifier” on their claim form, the additional services over the threshold amount should be covered. The “KX modifier” on the claim indicates that the requirements for an exception to the therapy cap have been met. The Centers for Medicare and Medicaid Services (CMS) has clearly stated that claims exceeding the cap that do not include the KX modifier will be denied.

CMS also noted that an automatic exceptions process will not apply in 2013; and the manual medical review process for annual per beneficiary services over $3700 in 2013 is in the process of being determined.

For more information, see CMS’ website announcement and their Therapy Cap Fact Sheet (PDF).

Karen Fletcher
Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.